ABCs First
A 65-year-old patient with COPD has an SpO2 of 89%, RR of 30, and is using accessory muscles to breathe. What is your first intervention?
What is elevate the HOB and increase O2?
You are assigned four patients. One is complaining of dizziness, another has a mild fever, a third has severe chest pain, and the fourth has a blood glucose of 200 mg/dL. Who do you assess first?
Who is the patient with severe chest pain?
Can you delegate the administration of a unit of packed red blood cells to an LPN?
What is no? The administration of blood products must be done by an RN due to the need for close monitoring for transfusion reactions.
A patient with pneumonia is receiving antibiotics and their condition is stable. After 2 hours, the patient begins to complain of shortness of breath and is agitated. What should you do?
What is assess the patient, assess O2 sat, and notify MD of status change.
A patient receiving a blood transfusion develops fever, chills, and back pain. What should you do immediately?
What is stop the transfusion?
A 50-year-old patient recovering from a stroke suddenly develops slurred speech and difficulty breathing. What is your priority action?
What is assess the airway and prepare to assist with ventilation if needed, as this could indicate a new or worsening stroke affecting the airway.
You have the following patients:
Who should you see first?
Who is the confused and agitated patient, as they are at risk for injury and may require immediate safety interventions?
Can you delegate measuring a patient's vital signs after they return from surgery to a Nursing Assistant?
What is No, the initial post-op assessment, including vital signs, must be done by the RN to monitor for complications such as hemorrhage or shock.
A patient with heart failure is complaining of sudden weight gain, shortness of breath, and swelling in the legs. What should be your first action?
What is assess lung sounds for fluid overload (crackles), check oxygen saturation, and notify the provider for possible diuretic orders.
A patient with sepsis is developing altered mental status, and their blood pressure is dropping to 85/50. What is your priority intervention?
What is begin IV fluids?
A patient recovering from surgery is drowsy and breathing shallowly with a respiratory rate of 8 breaths per minute after receiving IV morphine for pain. What is your priority action?
What is administer naloxone to reverse opioid-induced respiratory depression and closely monitor the patient's respiratory status?
You have four patients in the ER:
Who should you assess first?
Who is the patient with chest pain and ST-segment elevation, as they may be experiencing an ST-Elevation Myocardial Infarction (STEMI) and require immediate intervention to restore blood flow. ?
Can you delegate administering subcutaneous insulin to a stable patient to a Nursing Assistant?
What is no, administering medications, including insulin, must be done by an RN or LPN
You find a post-op patient with a rapid pulse, cool and clammy skin, and decreased urine output. What is your first intervention?
What is assess vital signs, increase IV fluids to maintain perfusion and call the provider, as this could indicate hypovolemia or shock?
A post-op patient 2 days after abdominal surgery reports increasing abdominal pain, and their abdomen is firm and distended. They have no bowel sounds and have not passed gas in 24 hours. What is your priority intervention?
What is keep patient NPO, notify the provider immediately, as this could indicate a bowel obstruction or paralytic ileus, requiring urgent intervention?
A patient with a tracheostomy tube becomes agitated and cyanotic, and their oxygen saturation drops to 82%. You notice the tracheostomy tube is dislodged. What is your first action?
What is attempt to replace the tracheostomy tube if trained or provide bag-valve-mask ventilation while calling for immediate help?
You have four patients:
Who should you prioritize first?
Who is the diabetic patient with blood glucose of 60 mg/dL?
Can you delegate teaching a patient about a low-sodium diet to a Nursing Assistant?
What is no, patient education requires clinical judgment and should be provided by the RN.
A patient with diabetes develops diaphoresis, tachycardia, and confusion. What is your priority action?
What is assess blood glucose?
A post-op patient has a Foley catheter in place. The nurse assesses the patient and notes no urine in present in the catheter. What should the nurse do?
What is assess the catheter for obstruction, palpate bladder for distention, and obtain a bladder scan?
A patient is in respiratory distress due to anaphylaxis. They are wheezing, have stridor, and are becoming cyanotic. What is your immediate intervention?
What is administer epinephrine IM, provide high-flow oxygen, and prepare for potential intubation if airway swelling continues?
You are assigned to the following patients:
Who is your first priority?
Who is the patient with atrial fibrillation and a heart rate of 150 bpm, as they may be at risk for hemodynamic instability or thromboembolic events?
Can you delegate inserting a Foley catheter for a stable post-op patient to an LPN?
Yes, inserting a Foley catheter can be delegated to an LPN
You walk into a room and find a patient unresponsive with a pulse and snoring respirations. What should you do first?
What is open the airway with head-tilt chin lift and bag if needed?
A patient with a known history of myocardial infarction presents to the emergency department with sudden onset of crushing chest pain radiating to the left arm, diaphoresis, and nausea. Their vital signs show a blood pressure of 100/60 mmHg and a heart rate of 120 bpm. What is your priority intervention?
What is administer aspirin to inhibit platelet aggregation, start supplemental oxygen to improve oxygenation, and prepare to administer nitroglycerin and morphine as prescribed to manage pain and reduce myocardial oxygen demand. Ensure continuous cardiac monitoring and notify the healthcare provider immediately.